Surgical strategies for coexisting glaucoma and cataract: an evidence-based update

OBJECTIVE: To assess short- and long-term control of intraocular pressure (IOP) with different surgical treatment strategies for coexisting cataract and glaucoma. DESIGN: Systematic literature review and analysis. METHOD: We performed a search of the published literature to identify all eligible articles pertaining to the surgical management of coexisting cataract and glaucoma in adults. One investigator abstracted the content of each article onto a custom-designed form. A second investigator corroborated the findings. The evidence supporting different approaches was graded by consensus as good, fair, weak, or insufficient. MAIN OUTCOME MEASURES: Short-term (24 hours or fewer) and long-term (more than 24 hours) IOP control. RESULTS: The evidence was good that long-term IOP is lowered more by combined glaucoma and cataract operations than by cataract operations alone. On average, the IOP was 3 to 4 mmHg lower in the combined groups with fewer medications required. The evidence was weak that extracapsular cataract extraction (ECCE) alone results in short-term increase in IOP and was insufficient to determine the short-term impact of phacoemulsification cataract extraction (PECE) on IOP in glaucoma patients. The evidence was weak that short-term IOP control was better with ECCE or PECE combined with an incisional glaucoma procedure compared with ECCE or PECE alone. The evidence was also weak (but consistent) that long-term IOP is lowered by 2 to 4 mmHg after ECCE or PECE. Finally, there was weak evidence that combined PECE and trabeculectomy produces slightly worse long-term IOP control than trabeculectomy alone, and there was fair evidence that the same is true for ECCE combined with trabeculectomy. CONCLUSIONS: There is strong evidence for better long-term control of IOP with combined glaucoma and cataract operations compared with cataract surgery alone. For other issues regarding surgical treatment strategies for cataract and glaucoma, the available evidence is limited or conflicting.     

Surgical strategies in patients with combined cataract and glaucoma

PURPOSE OF REVIEW: In the elderly population, the combined presence of cataract and glaucoma is a frequent condition. In this situation, several surgical options are possible: cataract surgery only and later maybe trabeculectomy, trabeculectomy only and later maybe cataract surgery, or combined cataract and glaucoma surgery. This review compares the different surgical options on the basis of their achievable postoperative intraocular pressure (IOP) level and success and complication rates. RECENT FINDINGS: The impression of better IOP regulation with trabeculectomy than with phacotrabeculectomy has been recently confirmed by an evidence-based review. Contrary to this finding, the success of deep sclerectomy or trabeculotomy does not seem to be compromised by simultaneous phacoemulsification. In eyes with previous glaucoma-filtering surgery, cataract surgery with clear corneal incision has no effect on mean IOP but increases the 3-year failure probability. For phacotrabeculectomy, moderate evidence of a beneficial effect of MMC on IOP regulation and only weak evidence for separating the incisions has been recently reported by another evidence-based review. SUMMARY: The choice of the preferred surgical method depends on the target pressure, the amount of glaucomatous damage, and the grade of visual disturbance caused by the cataract. Phacotrabeculectomy combined with mitomycin C achieves the best IOP lowering of all types of combined cataract and glaucoma surgery currently possible but is associated with potentially sight-threatening complications. In the absence of a low target pressure, phacotrabeculotomy or the combination of phacoemulsification with viscocanalostomy or deep sclerectomy may be the therapy of choice.     

260例青光眼白内障联合手术临床分析

目的：分析评价青光眼白内障联合手术的疗效。方法：对２６０例（２７９眼）行青光眼白内障联合手术的病例作回顾性分析,并将病人分为３组。Ⅰ组：白内障囊外摘除联合小梁切除术;Ⅱ组：白内障囊外摘除、人工晶体植入联合小梁切除术;Ⅲ组：超声乳化白内障吸出、人工晶体植入联合小梁切除术;并分析比较３组的术后视力、眼压和并发症。结果：３组病例术后视力≥０．３者分别为１６．３％、３２．４％和４３．５％,术后视力改善率分     

剥脱综合征并发白内障患者超声乳化术后2a眼压变化及其相关因素的临床研究

目的:研究剥脱综合征并发白内障患者和老年性白内障在超声乳化术后2a内眼压变化情况及相关因素。方法:对49例54眼剥脱综合征并发白内障的患者实施超声乳化人工晶状体植入术,依据眼压情况又分为剥脱综合征并发白内障(XFS)亚组(29例31眼)及剥脱综合征并发白内障和青光眼(XFG)亚组(20例23眼)。同期选择老年性白内障患者134例152眼行超声乳化人工晶状体植入术作为对照依据眼压情况分为白内障亚组(86例93眼)及并发开角青光眼组(POAG)亚组(48例59眼)。两组眼压用药控制正常后手术。比较两组在超声乳化术后2a内眼压的变化。结果:术前剥脱组基础眼压高于对照组(21.85±2.23mmHgvs18.62±3.12mmHg,P=0.002)。在超声乳化术后2a内,两组眼压均降低(17.60±3.23mmHgvs15.08±3.18mmHg,P=0.0037)。统计分析表明与术中灌注量相关。XFG组眼压降低更明显。结论:在超声乳化术后2a内,剥脱综合征组比对照组眼压降低明显。     

Trabeculectomy combined with phacoemulsification and intraocular lens implantation

It has recently become popular to use mitomycin C (MMC) with trabeculectomy. MMC helps to maintain effective filtration and long-term intraocular pressure (IOP) control, while the use of laser suture lysis has improved the safety of this procedure. We evaluated the outcome of trabeculectomy alone and of trabeculectomy plus phacoemulsification (PEA) and intraocular lens (IOL) implantation, each supplemented with MMC. The mean preoperative IOP for the trabeculectomy alone group was 22.4 +/- 3.2 mmHg(bleb+), 25.3 +/- 2.6 mmHg(bleb-), and that of the combined surgery group was 22.4 +/- 2.8 mmHg(bleb+), 21.0 +/- 3.5 mmHg(bleb-). Mean postoperative IOP for the two groups were 13.3 +/- 2.7 mmHg(bleb+), 17.1 +/- 4.4 mmHg(bleb-) and 11.9 +/- 2.7 mmHg(bleb+), 16.4 +/- 3.4 mmHg(bleb-), respectively. After 4.5 years, the success probability for postoperative IOP control was 38%(bleb+), 3%(bleb-) in the trabeculectomy alone group and 53%(bleb+), 10%(bleb-) in the combined surgery group (相似文献   

Protocol for mitomycin C use in glaucoma surgery

PURPOSE: To evaluate the results of a protocol described for mitomycin C (MMC) use in trabeculectomy or combined surgery (phacoemulsification and trabeculectomy). METHODS: A total of 143 eyes (60 trabeculectomies and 83 combined surgeries) of 124 patients were divided into four groups: group 1 (without MMC); group 2 (with 0.1 mg/ml MMC); group 3 (with 0.2 mg/ml MMC), and group 4 (with 0.4 mg/ml MMC). Two-minute MMC was used in every case in groups 2, 3 and 4. The results were analysed after 1 year of follow-up. Intraocular pressure (IOP) and complications were evaluated. Successful IOP control was defined when IOP was <21 mmHg and <16 mmHg if advanced glaucoma was present, always without additional medical treatment. RESULTS: Mean preoperative IOP decreased from 24.60 mmHg (SD 1.40 mmHg) to 13.47 mmHg (SD 0.37 mmHg) (p < 0.00001), 12 months postoperatively. Control in IOP was achieved in 79.02% of eyes. No significant differences were found in final mean IOP values (p > 0.196) or in postoperative complications (p > 0.120) in groups 2, 3 and 4. CONCLUSION: With the protocol described, a selection of concentration of MMC has been made in different clinical forms of glaucoma. No significant differences in IOP control and postoperative complications were noticed among the groups.     

超声乳化联合小梁切除术治疗青光眼合并白内障临床疗效观察

目的:评价白内障超声乳化联合小梁切除术治疗青光眼合并白内障的临床疗效。方法:回顾36例青光眼合并白内障患者行白内障超声乳化吸除人工晶状体植入联合小梁切除术,对术后视力、眼压及前房情况进行总结。结果:术后视力提高者占72.2%(26/36),术后随访末期眼压<21mmHg者占86.1%(31/36),功能性滤过泡占91.7%(33/36),术后并发症少。结论:超声乳化白内障吸除人工晶状体植入联合小梁切除术不但视力恢复好,而且青光眼术后并发症减轻,有利于眼压控制。     

Trabeculectomy combined with phacoemulsification and intraocular lens implantation

It has recently become popular to use mitomycin C (MMC) with trabeculectomy. MMC helps to maintain effective filtration and long-term intraocular pressure (IOP) control, while the use of laser suture lysis has improved the safety of this procedure. We evaluated the outcome of trabeculectomy alone and of trabeculectomy plus phacoemulsification (PEA) and intraocular lens (IOL) implantation, each supplemented with MMC. The mean preoperative IOP for the trabeculectomy alone group was 22.4 ± 3.2 mmHg(bleb+), 25.3 ± 2.6 mmHg(bleb?), and that of the combined surgery group was 22.4 ± 2.8 mmHg(bleb+), 21.0 ± 3.5 mmHg(bleb?). Mean postoperative IOP for the two groups were 13.3 ± 2.7 mmHg(bleb+), 17.1 ± 4.4 mmHg(bleb?) and 11.9 ± 2.7 mmHg(bleb+), 16.4 ± 3.4 mmHg(bleb?), respectively. After 4.5 years, the success probability for postoperative IOP control was 38%(bleb+), 3%(bleb?) in the trabeculectomy alone group and 53%(bleb+), 10%(bleb?) in the combined surgery group (≤?12 mmHg) and 65%(bleb+), 3%(bleb?) and 75%(bleb+), 10%(bleb?) (≤?14 mmHg)(Kaplan-Meier survival rate). With early complications, the frequency of shallow anterior chamber and choroidal detachment were significantly fewer in the combined surgery group. The combined surgery of PEA, IOL implantation and trabeculectomy is an effective procedure that offers visual rehabilitation, fewer early complications and good IOP control in patients with advanced, medically uncontrolled glaucoma and cataract.     

Combined phacoemulsification and goniotrephination on eyes with primary open-angle glaucoma and classical pseudoexfoliation glaucoma

BACKGROUND: Combined glaucoma and cataract operation has been demonstrated to be effective in controlling IOP and increasing visual acuity. Because of the differences between patients with primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXEG), for cataract and glaucoma surgery alone we evaluated the effects and complications for simultanous surgical management. PATIENTS AND METHODS: In a retrospective study 103 patients were examined who underwent a combined phacoemulsification and goniotrephination between January 1993 and January 1997 and had no surgery before (110 eyes with POWG, 22 eyes with PXEG). RESULTS: The average age in the POAG group (75.1 +/- 8.7 years) was significantly less than in the PXEG group (79.3 +/- 5.9 years) (P < 0.05). The mean preoperative IOP in PXEG (31.8 +/- 10.3 mmHG) was significantly higher than in POAG (25.0 +/- 6.4 mmHg) (P < 0.0005). Due to the combined surgery the mean intraocular pressure decreased in both groups < 10 mmHg (days 1 and 7). PXEG had a significantly higher IOP at day 3 than POAG (12.3 +/- 8.4 mmHg versus 8.5 +/- 5.7 mmHg) (P < 0.05) and developed after combined operation IOP peaks > 25 mmHg into a significantly higher level (P < 0.05). Moreover, zonulolysis, rupture of the posterior capsule, vitreous loss and persistence of inflammatory response occurred more often in PXEG, but there was no significant difference compared to POAG. CONCLUSION: PXEG has an higher incidence of typical problems of phacoemulsification, a temporary increase of IOP and prolonged inflammation after combined cataract and glaucoma surgery than POAG, but there is a similar risk compared to a single procedure.     

双切口小梁切除与超声乳化联合手术治疗青光眼合并白内障

目的评价双切口小梁切除联合超声乳化人工晶状体植入术治疗青光眼合并白内障的安全性及效果。方法使用双切口式小梁切除联合超声乳化人工晶状体植入术治疗各种青光眼合并白内障52例（54眼）,分析手术前、后视力和眼压变化,术中及术后并发症情况。结果随访6～12个月,术后视力改善明显,矫正视力≥O．3者38眼,占70．4％,眼压由术前平均（31．30±6．37）mmHg降为术后平均（14．97±2．44）mmHg,术中及术后无严重并发症发生。结论双切口小梁切除联合超声乳化人工晶状体植入治疗青光眼合并白内障是安全、有效的方法。     

三联术治疗青光眼合并白内障的疗效观察

目的:探讨三联术(白内障超声乳化吸除、后房型人工晶状体植入联合小梁切除术)治疗青光眼合并白内障患者的临床疗效。方法:青光眼合并白内障患者72例72眼行小梁切除联合白内障超声乳化吸除联合后房型人工晶状体植入术,观察术后视力、眼压、滤过泡及并发症等情况。结果:术后72例72眼患者视力均有不同程度的提高;术后眼压控制良好,术后3,18mo平均眼压分别为15.30±2.64mmHg和16.72±2.30mmHg,术后均无严重并发症。结论:小梁切除联合白内障超声乳化吸除联合后房型人工晶状体植入术具有切口小,眼压控制良好,能获得较满意的视力。     

超声乳化术联合小梁切除术治疗急性闭角性青光眼合并白内障

目的探讨晶状体超声乳化及人工晶状体植入术联合小梁切除术及术中应用丝裂霉素C（MMC）治疗急性闭角性青光眼合并白内障的临床效果。方法回顾分析13例（13只眼）急性闭角性青光眼（前房角粘连关闭均〉180°）合并白内障行透明角膜切口超声乳化及人工晶状体植入,联合小梁切除术及术中应用丝裂霉素,注意观察手术前、后的视力和眼压,手术并发症及滤过泡情况。结果术后随访时间3—6个月。13只眼眼压均降致正常范围,视力有不同程度提高;术后根据Kronfeld分类,Ⅰ、Ⅱ型功能滤过泡4只眼（30．8％）,非功能Ⅲ型滤过泡9只眼（69．2％）。结论透明角膜切口晶状体超声乳化及人工晶状体植入术联合小梁切除术及术中应用丝裂霉素（MMC）治疗急性闭角性青光眼合并白内障是一种安全、有效的治疗方法,可以明显降低眼压,提高视力。     

Effect of temporal corneal phacoemulsification on intraocular pressure in eyes with prior trabeculectomy with an antimetabolite

OBJECTIVE: To evaluate the effect of temporal corneal phacoemulsification on intraocular pressure (IOP) in eyes after primary trabeculectomy with intraoperative fluorouracil (5-FU) or mitomycin C (MMC). DESIGN: Retrospective case-control study. PATIENTS: Twenty-nine patients who were participants in a prospective randomized double-masked trial comparing the efficacies of intraoperative 5-FU and MMC and who underwent temporal corneal phacoemulsification after the primary trabeculectomy were matched to 29 patients enrolled in the same study who did not undergo cataract surgery. The 2 groups were matched for length of follow-up after the trabeculectomy and the antimetabolite used at the time of trabeculectomy. METHODS: Comparisons of IOP, visual acuity (VA), and the number of glaucoma medications were made between the 2 groups and within the groups at various follow-up intervals to detect any statistically significant differences. MAIN OUTCOME MEASURES: Intraocular pressure before phacoemulsification and at various times postoperatively were compared with IOP in the control group at the matched follow-up times. RESULTS: The mean of all IOP measurements beyond 3 months after phacoemulsification for each subject was significantly higher than the prephacoemulsification IOP (11.8+/-4.2 vs. 8.7+/-4.5 mmHg; P = 0.00003, paired t test). In contrast, the mean IOP remained stable in the control group during the equivalent time period (9.6+/-3.5 vs. 9.1+/-3.1 mmHg; P = 0.42, paired t test). Postphacoemulsification IOP was significantly higher than the corresponding IOP in the time-matched control group (P<0.003, analysis of covariance). Mean VA improved significantly after the phacoemulsification (P = 0.0002) but remained stable in the control group. CONCLUSION: Temporal corneal phacoemulsification can affect long-term IOP control after trabeculectomy with 5-FU or MMC.     

白内障超声乳化术治疗急性闭角型青光眼合并白内障

了解白内障超声乳化术治疗急性闭角型青光眼合并白内障的有效性。 方法:对2006-03-01/2010-10-31收治的急性闭角型青光眼合并白内障患者47例51眼,眼压稳定后行超声乳化联合人工晶状体植入术,术后均随访1~3a。 结果:术后47例51眼中44例48眼眼压下降,术前眼压22.98±3.22mmHg,术后眼压13.24±3.17mmHg(P<005),45例49眼视力较术前明显提高(P<0.05)。47例51眼术后前房深度加深,由术前1.542±0.314mm转为术后3.157±0.243mm(P<0.05)。 结论:白内障超声乳化术可以使急性闭角型青光眼前房加深,不同程度地开放已关闭的房角,改善周边窄房角的解剖状态,降低瞳孔阻滞后周边前房关闭的可能性,可以使升高的眼压下降,提高视力,是闭角型青光眼合并白内障患者安全有效的治疗途径。     

白内障超声乳化联合房角分离术治疗闭角型青光眼

目的：分析白内障超声乳化吸出+人工晶状体植入联合房角分离术治疗闭角型青光眼的临床效果。

方法：回顾性分析合并有白内障的闭角型青光眼患者,且房角关闭粘连范围≤180°的患者46例56眼,行白内障超声乳化吸出+人工晶状体植入联合房角分离手术,观察分析术前和术后眼压、视力、前房深度、前房角的变化。

结果：术后眼压全部控制在21mmHg(1mmHg=0.133kPa)以下,最佳矫正视力均有不同程度的提高,前房深度明显增加,房角均有不同程度开放。术中、术后无严重手术并发症。术前和术后眼压、前房深度、最佳矫正视力差异有统计学意义(P<0.05)。

结论：选择对合适的闭角型青光眼合并白内障的患者施行白内障超声乳化联合房角分离手术能够获得满意的临床效果。     

Combined clear cornea phacoemulsification in the treatment of pseudoexfoliative glaucoma associated with cataract: significance of trabecular aspiration and ab interno trabeculectomy

Background

In the present study, the effectiveness of combined cataract surgery and ab interno trabeculectomy (Trabectome) in exfoliation glaucoma (PEX) was compared with combined cataract surgery and trabecular aspiration.

Methods

In this retrospective comparative cohort outcome study, 27 consecutive patients (mean age 73.41 years?±?10.78) in group 1 suffering from visually significant cataract and PEX glaucoma (mean preoperative IOP 23.41 mmHg?±?5.86) were treated with phacoemulsification combined with Trabectome; and 28 consecutive patients (73.83 years?±?8.94) were treated with phacoemulsification combined with trabecular aspiration (mean preoperative IOP 22.22 mmHg?±?6.33). The intraocular pressure (IOP) and the number of antiglaucoma eyedrops before and after surgery were evaluated.

Results

Examinations were performed prior to surgery, 1 day, 6 weeks, 3 months, 6 months, and 1 year after surgery. In both groups there was a statistically significant decrease in postoperative IOP during the whole follow-up period. Comparing the two groups, there was a statistically significant lower IOP in the Trabectome group 1 day (p?=?0.019), 6 months (p?=?0.025), and 1 year (p?=?0.019) after surgery. Between the two groups, there was no statistically significant difference in the number of antiglaucoma eyedrops at any time.

Conclusions

Both procedures have the ability to significantly lower the postoperative IOP during the first year. However, clear cornea phacoemulsification combined with Trabectome seems to be more effective in IOP reduction in cases of PEX glaucoma associated with cataract.     

双切口超声乳化三联术治疗青光眼合并白内障疗效观察

目的观察经透明角膜切口行白内障超声乳化及人工晶体植入联合小梁切除术治疗青光眼合并白内障的临床疗效。方法回顾分析2012年1月至8月患青光眼白内障在我院行经透明角膜切口超声乳化白内障吸除及人工晶体植入联合小梁切除术(以下简称双切口超乳三联术)的患者13例(13只眼),记录手术前、后的视力和眼压,记求手术并发症和滤过泡情况。结果术后平均眼压为12.12 mm H g,术后3个月随访,眼压控制良好,术后视力均有显著提高,术后无严重并发症发生。结论双切口超乳三联术具有损伤小,术后反应轻,双切口互不干扰,保留经典小梁切除滤过通道,可更安全有效治疗青光眼合并白内障。     

A prospective randomized comparison of two techniques of combined cataract – glaucoma surgery

· Background: Small-incision cataract surgery combined with trabeculectomy offers new options for surgical treatment of patients with glaucoma and cataract. The purpose of this prospective randomized study was to compare the efficacy and safety of two different techniques of combined surgery: a one-site and a two-site approach. · Methods: Fifty eyes of 50 patients were included in this study. Twenty-five patients were randomly assigned to the one-site procedure and 25 patients to the two-site procedure. The one-site approach consisted of a superior tunnel phacoemulsification under a scleral flap with subsequent trabeculectomy. The two-site approach included a temporal corneal phacoemulsification combined with a separate-incision superior trabeculectomy. · Results: The preoperative mean intraocular pressure (IOP) of 29.8±4.9 mmHg dropped significantly to 15.9±3.2 mmHg. The mean follow-up time was 19±4.3 months (range 4–25 months). The reduction of IOP was more pronounced in the two-site group (50.1%) than in the one-site group (43%), but the difference was not statistically significant. Patients needed 2.2±1.7 antiglaucomatous medications preoperatively vs 0.52±1.39 postoperatively. Three patients (6%) required needling of encapsulated bleb, and two patients underwent a reoperation to control IOP. Mean visual acuity improved from 0.14±0.36 to 0.38±0.30 postoperatively. The most common complications after combined surgery were fibrinous exudation (24%) and hyphema (12%). · Conclusion:Both techniques of combined cataract and glaucoma surgery proved to be efficient and safe procedures to control IOP and to improve visual acuity. The reduction of IOP did not differ between the one-site approach and the two-site approach. Received: 2 February 1999 Revised version received: 12 April 1999 Accepted: 13 April 1999     

联合手术治疗青光眼合并白内障的临床观察

目的:探讨治疗青光眼合并白内障的手术方法及临床效果。方法:对45例45眼青光眼合并白内障患者施行白内障超声乳化及人工晶状体植入联合隧道内小梁切除术。结果:术前视力<0.1者32眼,0.1～0.3者13眼。术后视力<0.1者6眼(13%),0.1～0.5者22眼(49%),>0.5者17眼(38%)。术前眼压26～60mmHg,术后42例眼压降至正常范围,3例经局部按摩、滴药后降至正常,平均眼压12.78±2.70mmHg。随访6～12mo,无1例眼压再升高。3例视力下降,经戴镜矫正视力提高。并发症主要是角膜水肿和虹膜炎症反应。结论:白内障超声乳化人工晶状体植入联合隧道内小梁切除术是治疗青光眼合并白内障的理想方法。     

透明角膜切口白内障超声乳化联合青光眼手术的疗效分析

目的:观察透明角膜切口白内障超声乳化人工晶状体植入联合小梁切除术(以下简称超声乳化三联术)治疗青光眼合并白内障的临床疗效和安全性。方法:回顾性分析使用透明角膜切口超声乳化三联术治疗各种类型的青光眼合并白内障患者127例(128眼)手术前、后的视力和眼压,手术并发症和滤过泡情况。结果:术后视力迅速恢复,矫正视力较术前明显提高,随访6mo～2a,113眼≥0.5(88.3%);眼压较术前明显降低,11眼术后眼压<20mmHg,16眼加滴1～2种降压药后眼压控制满意且稳定。术后并发症少,功能性滤过泡83.6%。结论:透明角膜切口超声乳化白内障吸除人工晶状体植入联合小梁切除术治疗青光眼合并白内障,不但能良好地控制眼压,迅速恢复视力。而且并发症少,手术适应证广,在白内障青光眼并存情况下采用超声乳化三联手术是安全、有效、可靠的治疗方法。